CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Acupuncture services — coverage criteria

Defines coverage, limits, coding, and provider requirements for acupuncture services for Neighborhood Health Plan of Rhode Island members across Commercial and Medicaid plans (excluding Extended Family Planning).

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyAcupuncture services — coverage criteria

Policy CodePolicy N/A

Change TypeExclusions updatedvisit limit clarified

Effective DateFeb 1, 2022

Next Review Date

Key ActionVerify member eligibility, coverage, and prior authorization; limit treatment to 12 visits per plan year.

SourceLink

POLICY UPDATE CHANGES

Updated Coverage Exclusions to include Medicaid and INTEGRITY language.

Specified treatment visit limit of 12 visits per plan year.

12maximum visits per plan year

3covered diagnoses

4approved procedure codes

Coverage Criteria for Acupuncture

Coverage criteria

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Provider qualifications: Performed by a provider who has successfully completed a course approved by the American Board of Medical Acupuncture (ABMA) and meets Rhode Island Department of Health licensure requirements for doctors of acupuncture.

Covered diagnosis: Patient has one of the following diagnoses: chronic low back pain; fibromyalgia; chronic migraine.

Visit limit: Treatment is limited to 12 visits per plan year.12 visits per plan year

The policy excludes certain adjunctive therapies and settings. Specifically, adjunctive therapies such as herbs, oriental massage, moxibustion, and cupping are not covered. Also excluded are acupuncture delivered in lieu of anesthesia or used as an anesthetic during surgical procedures, and the use of precious metal needles (for example, gold or silver). Acupuncture services are limited to office settings and are not covered when performed in the home, nursing, residential, domiciliary, or custodial facilities. Acupuncture assistants will not be separately reimbursed, and services not specifically listed as covered are excluded. The exclusion language has been expanded to reference Medicaid and INTEGRITY/In Lieu Of Payment guidance.

Any acupuncture service that does not meet the policy’s medical necessity criteria or that lacks supporting documentation in the medical record is subject to denial or may be considered not medically necessary. Neighborhood may request medical records to verify the services billed and will follow CMS documentation standards when reviewing medical necessity.

Coding and Visit Limits

Approved acupuncture CPT codesCPTCovered

97810	Acupuncture, 1 or more needles; without electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient.
97811	Acupuncture, 1 or more needles; without electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient; with re-insertion of needle(s) (List separately in addition to code for primary procedure).
97813	Acupuncture, 1 or more needles; with electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient.
97814	Acupuncture, 1 or more needles; with electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s) (List separately in addition to code for primary procedure).

inv-05: Annual visit limit — 12 visits per plan year

Annual visit limitTreatment is limited to 12 visits per plan year.

ScopeLimit applies to acupuncture services subject to medical review for covered diagnoses (chronic low back pain, fibromyalgia, chronic migraine).

Plan year definitionLimit counts visits within the plan year (12 visits total across covered diagnoses).

Provider Actions, Authorization & Documentation

Prior Authorization

Prior Authorization Required

Providers must verify member eligibility, coverage and obtain prior authorization when required before rendering services. Services are limited to 12 visits per plan year unless otherwise authorized.

Prior authorization and visit limit: Treatment is limited to 12 visits per plan year; providers must confirm plan-specific prior authorization requirements via Neighborhood's Prior Authorization Reference page or contact Provider Services at 1-800-963-1001.

Denial Risk

Medical Necessity and Denial Risk

All services must be medically necessary and supported by applicable coverage criteria. Neighborhood may use LCDs, NCDs, InterQual, Rhode Island EOHHS guidance, and Neighborhood Clinical Medical Policies (CMP) to determine medical necessity. Services that do not meet Neighborhood's medical necessity criteria or are unsupported by the medical record may be denied.

Services covered only for specified diagnoses: acupuncture covered only for chronic low back pain, fibromyalgia, and chronic migraine.
Denial risk: services not medically necessary per LCD/NCD/InterQual/EOHHS/CMP may be denied.

Documentation Required

Documentation Requirement

Neighborhood may request medical records for any billed service. Documentation in the medical record must support the services billed and the medical necessity for those services. Documentation standards follow CMS guidance.

Medical records must include evidence to support diagnosis, treatment rationale, and number of visits billed.
Neighborhood reserves the right to request records to substantiate reimbursement.

Billing Rule

Non‑covered Settings and Excluded Modalities

Certain settings and modalities are not covered. Acupuncture is limited to office settings and is not covered when performed in the home, nursing, residential, domiciliary, or custodial facilities. Adjunctive modalities such as herbs, oriental massage, moxibustion, cupping, use of precious metal needles, acupuncture as an anesthetic or in lieu of anesthesia, and services performed by acupuncture assistants separately billed are excluded.

Non‑covered settings: home, nursing, residential, domiciliary, custodial facilities.
Excluded adjunctive modalities: herbs, oriental massage, moxibustion, cupping, precious metal needles, acupuncture in lieu of anesthesia, acupuncture as an anesthetic, acupuncture assistants not separately reimbursed.

Background

Acupuncture is the technique of inserting thin needles through the skin at specific points in the body to help control pain and other symptoms. Under this policy, coverage is limited to a defined set of chronic pain diagnoses (chronic low back pain, fibromyalgia, and chronic migraine) and requires services to be provided by appropriately qualified providers; treatment is limited to 12 visits per plan year.

Definitions & Provider Qualifications

inv-12: Definition of acupuncture — inserting thin needles at specific points to control pain and symptoms

DefinitionAcupuncture is the technique of inserting thin needles through the skin at specific points in the body to control pain and other symptoms.

ModalityInvolves placement of thin needles at specified body points; electrical stimulation when billed is reflected in CPT coding (per coding section).

inv-13: Provider qualification — ABMA course completion and Rhode Island DOH licensure requirements for doctors of acupuncture

Minimum qualificationProvider must have successfully completed a course approved by the American Board of Medical Acupuncture (ABMA).

LicensureProvider must meet Rhode Island Department of Health requirements for licensure as a doctor of acupuncture per state Rules and Regulations.

Performance requirementAcupuncture must be performed by a licensed doctor of acupuncture to meet coverage criteria.